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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426217249
Report Date: 12/03/2024
Date Signed: 12/03/2024 11:11:43 AM

Document Has Been Signed on 12/03/2024 11:11 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:PENA FCC AKA JAVI AND ALI FAMILY CHILD CAREFACILITY NUMBER:
426217249
ADMINISTRATOR/
DIRECTOR:		PENA, KARINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 720-0517
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
12/03/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:04 AM
MET WITH:Karina PenaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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This is a change of location, previous facility number 426216315.

On 12/03/24, at 9:04A.M., Licensing Program Analyst (LPA) Joaquin Mendez conducted an announced Pre-license Inspection of the abovementioned residence and met with Applicant Karina Pena. LPA informed Applicant of the nature and purpose of the inspection. Applicant informed LPA of the intention to maintain operating hours of a Family Childcare Home (FCCH) from 5:00 AM-11:00 PM, Monday- Saturday. Applicant also intends to care for children 0 years of age to 13 years of age. Applicant was informed changes in licensing hours and/or the ages of children supervised and cared for can be altered upon notifying CCLD of the given modifications and/or changes. LPA notes no children are on site at the time of the inspection. There are 3 adults residing in the home and 3 adults are cleared through The Guardian website.



LPA, in the company of Applicant, toured the interior and exterior of the 2-story residence in its entirety. The residence has four (4) bedrooms, three (3) bathrooms, living room, Family room (second floor), kitchen, dining room, washroom (second floor), garage, and back yard. The areas to be used for childcare within the residence is the dining room (furnished into daycare), hallway restroom, and backyard area. While the remainder of the home is excluded from day-care (see LIC812). LPA observed a gate at the bottom of the staircase preventing access to the upstairs access of the home. Additionally, the LPA observed locks and doorknob covers on bedroom, and garage door downstairs, making these rooms inaccessible to children in care. LPA observed retractable gates at both entrances to the kitchen making the kitchen inaccessible to children in care.

· LPA observed a regulation fire extinguisher (2A10BC) in the area for childcare which was purchased on 10/21/2024. LPA reminded Applicant of the responsibility to service or purchase a regulation fire extinguisher annually.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Joaquin Mendez
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: PENA FCC AKA JAVI AND ALI FAMILY CHILD CARE
FACILITY NUMBER: 426217249
VISIT DATE: 12/03/2024
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· The residence has multiple combination smoke/carbon monoxide detectors. A combination smoke/carbon monoxide detector in the dining room wall and was tested at 9:36A.M. and found to be operable.
· The hall had one (1) closet and is being used as storage for children’s toys and activities at the time of inspection.
· LPA observed the residence to be clean and orderly.
· LPA observed a fireplace in the living room secured with a locked-door and screen preventing access to children in care.
· The residence has spaced and ventilation for children in care.
· The restroom to be used for children in care is observed to be clean and free of toxins.
· Sharps are in elevated locked cabinet in the kitchen making them inaccessible to children in care.
· Medications are stored upstairs in the inaccessible to children in care.
· Chemicals and cleaning supplies are in the locked garage and inaccessible.
· Kitchen stove had knob covers making them inaccessible to children in care.
· Water will be supplied by individual cups and the home has a water dispensing unit easily accessible for children in care.

The back yard is fully fenced by wood fencing and will be used by FCCH.
· LPA observed the back yard to be enclosed by wooden fencing with an emergency exit gate if needed. The footing in the area is artificial turf, grass, and concrete.
· In the Back yard are various toys and equipment for the enjoyment of children of various ages. Additionally, LPA reminded Applicant to replace play equipment and toys when such items began to degrade or are not in good repair.
· LPA observed no bodies of water in the back yard.

LPA's record review revealed Applicant's documents noted below.
· CCLD orientation certification on was obtained on 7/21/2021.

· Applicant completed Preventative Health Training on 7/30/2021.

SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Joaquin Mendez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: PENA FCC AKA JAVI AND ALI FAMILY CHILD CARE
FACILITY NUMBER: 426217249
VISIT DATE: 12/03/2024
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· Pediatric CPR/First Aid (EMSA approved) was completed on 7/02/2024 (expiration 7/2026).

· Mandated Reporter training was completed on 7/17/2024 (expiration 7/17/2026)


· LPA reminded Applicant of obligation to maintain current training and certifications.
No prohibited equipment will be allowed or used in the home. No baby bouncers, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

Applicant Karina Pena was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

The applicant provided proof of control of property. LPA observed the deed to property on today’s inspection.
Applicant Karina Pena states she will not for facility to open to decide on the needs for offer Incidental Medical Services (IMS). Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 2202-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TW} and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at http://www.ada.gov/childqanda.htm

LPA reviewed with Applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist (LIC126) was provided to the applicant.

LPA discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Joaquin Mendez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: PENA FCC AKA JAVI AND ALI FAMILY CHILD CARE
FACILITY NUMBER: 426217249
VISIT DATE: 12/03/2024
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webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed Applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and recommended they register all infant devices with the CPSC to be notified of any recalls of infant devices or their purchased equipment.

On this date, 12/02/24, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant Karina Pena was informed of the MyChildCarePlan.com site, a consumer education
website that helps families obtain childcare by connecting them to childcare providers and
Resource and Referral Agencies (R&Rs) throughout California.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.



To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Joaquin Mendez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA BARBARA CC RO, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: PENA FCC AKA JAVI AND ALI FAMILY CHILD CARE
FACILITY NUMBER: 426217249
VISIT DATE: 12/03/2024
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The home meets Title 22 Division 12 requirements of a Large FCCH license. License is pending LPM approval.

A notice of site visit was given to applicant Karina Pena, and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the Applicant Karina Pena in the applicant’s preferred language, Spanish.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Joaquin Mendez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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